K. Michelle Hunnicutt Hollenbaugh Texas A&M University- Corpus Christi

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1 K. Michelle Hunnicutt Hollenbaugh Texas A&M University- Corpus Christi

2 Overview of DBT Intro to DBT & Eating Disorders Treatment targets and behavior chain analysis with eating behaviors Specific DBT skills for disordered eating behaviors

3 Developed by Marsha Linehan (1993) A multifaceted, cognitive-behavioral approach that includes aspects of mindfulness practice, behaviorism and dialectics. Originally developed for clients with Borderline Personality Disorder Now used transdiagnostically with clients struggling with various disorders Helps clients gain insight and skills to manage their thoughts, emotions, and behaviors

4 DBT therapists balance validation and change Change is constant, there are no absolutes Two seemingly conflicting ideas or view points can both be true

5 There are several modes of treatment in standard DBT: Individual therapy Addresses target behaviors Skills training groups Mindfulness Interpersonal Effectiveness Emotion Regulation Distress Tolerance Between session skills coaching Promotes skills generalization and reinforces skill use Consultation team Support for counselors, maintains treatment fidelity

6 Researchers believe many eating disordered behaviors are related to an inability to effectively regulate emotions DBT targets emotion dysregulation and its symptoms Individuals who struggle with eating disorders are more likely to struggle with other DSM-5 diagnoses. They are also more likely to struggle with life threatening behaviors. DBT may be well suited to help clients who are considered treatment resistant

7 Address eating disorders in addition to full DBT Clients who struggle with NSSI/suicidal thoughts and eating disorders Add DBT in addition to current eating disorder treatment Clients who are not responding to traditional eating disorder treatments, and/or struggle with NSSI/suicidal thoughts Implement full DBT for Stage 2 clients who wish to address quality of life interfering behaviors Clients who are not struggling with life threatening behaviors

8 Biological Predisposition for Emotional Sensitivity/Reactivity Invalidating Environment Pervasive Emotion Dysregulation

9 Biological Predisposition for Emotional sensitivity AND nutritional vulnerability Invalidating Environment (includes media) Disordered Eating Behavior (pervasive emotion dysregulation)

10 DBT INTERVENES AVOIDANCE OR ESCAPE CUE EMOTION DYSREGULATION DBT teaches how to avoid or distract without disordered eating Binging/Purging/Restricting TEMPORARY RELIEF Teach skills on how to regulate emotions and reduce vulnerability to cues Teach how to stop the behavior; which stops reinforcement

11 Stage 1 Decrease life-threatening behaviors Decrease therapy interfering behaviors Decrease quality of life interfering behaviors Increase behavioral skills Stage 2 Decrease post-traumatic stress Stage 3 Individual goals Stage 4 Finding Freedom and Joy

12 Binge eating & Purging Mindless Eating Over exercising Being underweight Restricting Preoccupation with food, urges, and cravings Capitulating Apparently Irrelevant behaviors

13 Behaviorism is central to DBT Each problem behavior is evaluated via a behavior chain analysis Client and counselor work together to identify steps that lead to the disordered eating behavior Create a new chain leading to use of skills and effective emotion regulation

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15 Problem Behavior (Disordered Eating Behavior) Prompting Event Vulnerabilities Consequences Thoughts, feelings, actions, or beliefs that led up to the disordered eating behavior New Behavior Thoughts, feelings, actions (skills used), or beliefs that will lead to the new behavior

16 Complete the Behavior Chain Analysis based on a client you have worked with or might work with. Choose one behavioral treatment target and practice working through the behavior chain. Feel free to ask questions!

17 Over structured eating vs. no eating plan at all No activity vs. over-activity Apparent compliance vs. active defiance

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19 Client will commit to abstaining from disordered eating behaviors permanently, AND the client commits to reducing them when they do occur This synthesis of two seeming conflicting ideas will allow flexibility for the client during treatment to completely abstain from these behaviors, while also working to reduce them when they do occur.

20 REASONABLE MIND WISE MIND EMOTION MIND

21 Binge eating/purging/restricting comes from emotion mind Mindful Eating clients are encouraged to be acutely aware of every bite they are taking, and to slowly savor the flavors, smells, and textures of their foods. By engaging in this practice regularly, clients will be better able to use their mindfulness skills to be aware of their eating behaviors, and avoid dialectical dilemmas such as over-structured eating vs. no structure to eating at all

22 Urge Surfing Common in many other treatment approaches Clients are taught to be aware of the urge, experience it as an ebb and flow, and in that awareness remind themselves that the urge will pass

23 Alternate Rebellion (Effectively) Rebellion among clients with eating disorders takes the form of engaging in binging/purging or restricting behaviors in order to fight against treatment, family members, society, or the therapist. the goal is to help clients validate their urge to rebel, but do so in a manner that is not harmful and does not include engaging in eating disordered behaviors.

24 Burning your bridges Invites the client to engage in radical acceptance regarding the idea that they will burn the bridge to binging and purging behaviors. Evaluating the Pros and Cons In DBT for eating disorders, this is completed on an index card at the very beginning of treatment, and reviewed daily

25 Get in a small groups. In your group, work through the pros and cons of engaging in a specific behavior related to eating disorders. Have someone right down the groups responses for each. What are the benefits of doing this? What challenges do you foresee?

26 Next Meal or Snack Rule In traditional DBT, clients must wait 24 hours after engaging in a behavior to contact the clinician This may be too long for clients struggling with eating disordersand is shortened when specifically targeting disordered eating behaviors

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29 For Clients to Create Their Own Diary Card: Go to In the menu on the left, click Everyday DBT and then click extras Decide which version of the diary card you wish to use, then click printer friendly version for it to begin download into a word document Once it has downloaded, make your changes, save, and print!

30 DBT skills diary DBT diary card and skills app

31 Questions? Thank you!

32 Federici, A., & Wisniewski, L. (2013). Dialectical behavior therapy for clients with complex and multidiagnostic eating disorder presentations. In L. H. Choate, L. H. Choate (Eds.), Eating disorders and obesity: A counselor's guide to prevention and treatment (pp ). Alexandria, VA, US: American Counseling Association. Linehan, M. M. (1993a). Cognitive-behavioral treatment for borderline personality disorder. New York: The Guilford Press. Linehan, M. M. (2015). DBT Skills training manual (2nd ed.). New York, NY: Guilford Press. Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. New York, NY, US: Guilford Press. Wisniewski, L., & Ben-Porath, D. D. (2015). Dialectical behavior therapy and eating disorders: The use of contingency management procedures to manage dialectical dilemmas. American Journal Of Psychotherapy, 69(2),

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